ED visit for migraine headache 99284 or 99285?

Can I get an opinion regarding level of service for this ED visit? There is a comprehensive ros, pfsh and exam- too lengthy to include.
Patient says that she has her typical migraine headache, which is right frontal and parietal. This began about an hour prior to ED arrival, and was on relieved by Imitrex. Her migraines are precipitated by stress, and she was in the process of teaching a class when the headache began. She says this headache began somewhat more quickly than her other migraines, though it has gradually worsened and was not maximally intense at onset. She said that she herself considered whether this was a subarachnoid hemorrhage, but does not wish to pursue any testing for that diagnosis as she thinks this is her normal migraine. Patient says she does take Topamax, and in July had a normal ophthalmologic evaluation, and doesn't have pain in her eye, so this does not sound as though she has glaucoma as cause of her headache.
Patient is a 39 year old female presenting with headaches. The history is provided by the patient.This is a recurrent problem. The current episode started less than 1 hour ago. The problem occurs constantly. The problem has not changed since onset. The headache is associated with bright light, emotional stress and loud noise. The pain is located in the right unilateral, frontal and parietal region. The pain quality is described as throbbing. The pain is at a severity of 9/10. The pain does not radiate. Associated symptoms include nausea. Pertinent negatives include no anorexia, no fever, no malaise/fatigue, no chest pressure, no near-syncope, no orthopnea, no palpitations, no syncope, no shortness of breath and no vomiting. Treatments Tried: imitrex. The treatment provided no relief.

MDM:

Patient was given Toradol 30 mg IV, Compazine 10 mg IV, and Benadryl 25 mg IV.

The patient, says that she does not feel this is anything different than her typical migraine headache, and does not want head CT or lumbar puncture. Understands the risks of not performing CT or LP.

On repeat assessment patient's pain about 10 minutes after the above medicines is 8/10. Patient remembers Dilaudid has helped in the past. She is given Dilaudid 1mg IV.

As of 1247, pain has resolved. No nausea. No new symptoms. Feels fine, wants to go home, knows to come back if worse.

With Dilaudid being a narcotic and the number of IV's the patient had, should this increase the level to a 99285?

Thanks

Medcoder

ED visit 99284 or 99285

Even if you go to complexity of high risk, you don't have either data or the number of diagnoses/treatment options at the higher level. The doctor wanted to do some tests, but the patient didn't receive them, and was discharged from the hospital.

I think 99284.

There is a lot of controversy about whether an ED doctor can get four points for diagnosis: new problem with work up planned. Todd Thomas posted a discussion of this on another forum. I'll ask him if I can re-post it here.

You need to check the guideline on the MDM, Exam, Hx level to determine the appropriate code

You need to check the medical record in order to determine the correct MDM, Exam, HX to find the appropriate E/M codes based off the ROS, PFSH, Presenting Problem ( min, sl/m, ls- lw severity, hs-high severity, sri-stable, recovering, improving, rt- response to therapy, udsc0 unstable, develop signifcant comp or new problem), MDM- Medical decision Making, Hx- Comprehensive, Detailed, Expnd Problem Focus, Problem Focus. You need to determine what is the appropriate E/M levels base off the medical record and patients information to determine what the actually correct E/M code would be. Because if you code and it get bill, it may get rejected and then you will waste time doing an appeal. A person can have a migraine, but it doesn't mean it will fall under the higher code as a CHF or Diabetes ( a Chronic Condition, in other words), usually one that would change the DRG for higher payment can affect the E/M codes.